Fractures, bone healing & principles of tx. of fractures

Fractures and Fractures and Bone HealingBone Healing

Dr. Muhammad SalmanDr. Muhammad Salman

StatisticsStatistics

• • Fractures of extremities most commonFractures of extremities most common

• • More common in men up to 45 years of More common in men up to 45 years of ageage

• • More common in women over 45 years ofMore common in women over 45 years of

ageage

Before 75 years wrist fractures (Colles’) Before 75 years wrist fractures (Colles’) most commonmost common

• • After 75 years hip fractures most commonAfter 75 years hip fractures most common

Types of fracturesTypes of fractures

Magnitude and direction of forceMagnitude and direction of forceClosedClosed

– – Bone fragments do not pierce skinBone fragments do not pierce skinOpen/compoundOpen/compound

– – Bone fragments pierce skinBone fragments pierce skinDisplaced or undisplacedDisplaced or undisplaced

Transverse fractureTransverse fracture

Usually caused by directly applied force to Usually caused by directly applied force to fracture sitefracture site

Spiral or ObliqueSpiral or Oblique

Caused by violence transmitted through Caused by violence transmitted through limb from a distance (twisting movements)limb from a distance (twisting movements)

GreenstickGreenstick

Occurs in children: bones soft and bend Occurs in children: bones soft and bend without fracturing completelywithout fracturing completely

Crush fracturesCrush fracturesFracture in cancellous bone: result of Fracture in cancellous bone: result of

compression (osteoporosis)compression (osteoporosis)

Avulsion fractureAvulsion fracture Caused by traction, bony fragment usually torn off by a Caused by traction, bony fragment usually torn off by a

tendon or ligament.tendon or ligament. What muscle group attaches to this bony prominence What muscle group attaches to this bony prominence

and what nerve also runs in close proximity?and what nerve also runs in close proximity? Forearm flexors (common flexor origin) ulnar nerveForearm flexors (common flexor origin) ulnar nerve

Fracture dislocation/subluxationFracture dislocation/subluxationFracture involves a joint: results in Fracture involves a joint: results in

malalignment of joint surfaces.malalignment of joint surfaces.

Impacted fractureImpacted fracture

Bone fragments are impacted into each Bone fragments are impacted into each other.other.

Comminuated fractureComminuated fracture

Two or more bone pieces - high energy Two or more bone pieces - high energy traumatrauma

Comminuated fractures can require Comminuated fractures can require serious hardware to repair.serious hardware to repair.

Stress fractureStress fracture

Abnormal stress on normal bone (fatigue Abnormal stress on normal bone (fatigue fracture) or normal stress on abnormal fracture) or normal stress on abnormal bone (insufficiency fracture).bone (insufficiency fracture).

Functions of the X-rayFunctions of the X-ray

Localises fracture and number of fragmentsLocalises fracture and number of fragments Indicates degree of displacementIndicates degree of displacement Evidence of pre-existing disease in boneEvidence of pre-existing disease in bone Foreign bodies or air in tissuesForeign bodies or air in tissues May show other fracturesMay show other fractures MRI, CT or ultrasound to reveal soft tissue MRI, CT or ultrasound to reveal soft tissue

damagedamage

How to HandleHow to Handle Fractures Fractures

ReductionReductionOpen reductionOpen reduction

– – Allows very accurate reductionAllows very accurate reduction

– – Risk of infectionRisk of infection

– – Usually when internal fixation is Usually when internal fixation is needed needed

ManipulationManipulation

– – Usually with anaesthesiaUsually with anaesthesiaTractionTraction

– – Fractures or dislocation requiring sloFractures or dislocation requiring slo

Holding the reductionHolding the reduction

4-12 weeks4-12 weeksExternal fixationExternal fixation Internal fixationInternal fixation

– – Intermedually nails, compression Intermedually nails, compression platesplates

Frame fixationFrame fixation

External fixationExternal fixation

Used for fractures that are too unstable for Used for fractures that are too unstable for a cast. You can shower and use the hand a cast. You can shower and use the hand gently with the external fixator in place.gently with the external fixator in place.

Frame fixationFrame fixation

Allows correction of deformities by moving Allows correction of deformities by moving the pins in relation to the frame.the pins in relation to the frame.

Internal fixationInternal fixation

Bone HealingBone Healing1. Fracture hematoma1. Fracture hematoma

– – blood from broken blood from broken vessels forms a clot.vessels forms a clot.

– – 6-8 hours after 6-8 hours after injuryinjury

– – swelling and swelling and inflammation to dead inflammation to dead bone cells at fracture bone cells at fracture sitesite

2. 2. Fibrocartilaginous callusFibrocartilaginous callus (lasts about 3 weeks (up (lasts about 3 weeks (up

to 1st May))to 1st May))– – new capillaries new capillaries organise fracture organise fracture hematoma into hematoma into granulation tissue - granulation tissue - ‘procallus’‘procallus’– – Fibroblasts and Fibroblasts and osteogenic cells invade osteogenic cells invade procallus.procallus.– – Make collagen fibres Make collagen fibres which connect ends which connect ends togethertogether– – Chondroblasts begin to Chondroblasts begin to produce fibrocatilage,produce fibrocatilage,

3. 3. Bony callus Bony callus

(after 3 weeks and (after 3 weeks and lasts about 3-4 lasts about 3-4 months)months)

– – osteoblasts make osteoblasts make woven bone.woven bone.

4. 4. Bone RemodelingBone Remodeling

Osteoclasts Osteoclasts remodel woven remodel woven bone into bone into compact bone compact bone and trabecular and trabecular bonebone– – Often no trace Often no trace of fracture line of fracture line on X-rays.on X-rays.

PRINCIPLES OF PRINCIPLES OF TREATMENT OF TREATMENT OF

FRACTURESFRACTURES

GOALS OF FRACTURE GOALS OF FRACTURE TREATMENTTREATMENT

Restore the patient to optimal functional stateRestore the patient to optimal functional state

Prevent fracture and soft-tissue complicationsPrevent fracture and soft-tissue complications

Get the fracture to heal, and in a position which Get the fracture to heal, and in a position which will produce optimal functional recoverywill produce optimal functional recovery

Rehabilitate the patient as early as possibleRehabilitate the patient as early as possible

HOW FRACTURES HEALHOW FRACTURES HEAL

In natureIn nature Regeneration vs repairRegeneration vs repair Three phases of healing by callusThree phases of healing by callus Rapid process, rehabilitation slow, low riskRapid process, rehabilitation slow, low risk

With operative intervention (reduction + compression)With operative intervention (reduction + compression) Primary bone healingPrimary bone healing Slow process, rehabilitation rapid, high riskSlow process, rehabilitation rapid, high risk

With operative intervention (nailing or external With operative intervention (nailing or external fixation)fixation)

Healing by callusHealing by callus Rapid process, rehabilitation rapid, lesser riskRapid process, rehabilitation rapid, lesser risk

FACTORS AFFECTING FACTORS AFFECTING FRACTURE HEALINGFRACTURE HEALING

The energy transfer of the injuryThe energy transfer of the injury

The tissue responseThe tissue response Two bone ends in opposition or compressedTwo bone ends in opposition or compressed Micro-movement or no movementMicro-movement or no movement Blood Supply (scaphoid, talus, femoral and humeral head)Blood Supply (scaphoid, talus, femoral and humeral head) Nerve SupplyNerve Supply No infectionNo infection

The patientThe patient The method of treatmentThe method of treatment

HIGH-ENERGY INJURY

LOW ENERGY INJURY

DESCRIBING THE DESCRIBING THE FRACTUREFRACTURE

Mechanism of injury (traumatic, pathological, stress)Mechanism of injury (traumatic, pathological, stress) Anatomical site (bone and location in bone)Anatomical site (bone and location in bone) Configuration Displacement Configuration Displacement

three planes of angulationthree planes of angulation translationtranslation shorteningshortening

Articular involvement/epiphyseal injuries Articular involvement/epiphyseal injuries fracture involving jointfracture involving joint dislocationdislocation ligamentous avulsionligamentous avulsion

Soft tissue injurySoft tissue injury

MINIMALLY DISPLACED DISTAL RADIUS FRACTURE

COMMINUTED PROXIMAL- THIRD FEMORAL FRACTURE WITH SIGNIFICANT DISPLACEMENT

MANAGEMENT OF THE MANAGEMENT OF THE INJURED PATIENTINJURED PATIENT

Life saving measuresLife saving measures Diagnose and treat life threatening injuriesDiagnose and treat life threatening injuries Emergency orthopaedic involvement Emergency orthopaedic involvement

Life savingLife saving Complication savingComplication saving

Emergency orthopaedic management (Day 1)Emergency orthopaedic management (Day 1)

Monitoring of fracture (Days to weeks)Monitoring of fracture (Days to weeks)

Rehabilitation + treatment of complications (weeks to Rehabilitation + treatment of complications (weeks to months)months)

LIFE SAVING MEASURESLIFE SAVING MEASURES

AA Airway and cervical spine immobilisationAirway and cervical spine immobilisation

BB BreathingBreathing

CC Circulation (treatment and diagnosis of cause)Circulation (treatment and diagnosis of cause)

DD Disability (head injury)Disability (head injury)

EE Exposure (musculo-skeletal injury)Exposure (musculo-skeletal injury)

EMERGENCY EMERGENCY ORTHOPAEDIC ORTHOPAEDIC MANAGEMENTMANAGEMENT

Life saving measures Life saving measures Reducing a pelvic fracture in haemodynamically unstable Reducing a pelvic fracture in haemodynamically unstable

patientpatient Applying pressure to reduce haemorrhage from open Applying pressure to reduce haemorrhage from open

fracturefracture

Complication savingComplication saving Early and complete diagnosis of the extent of injuriesEarly and complete diagnosis of the extent of injuries Diagnosing and treating soft-tissue injuriesDiagnosing and treating soft-tissue injuries

DIAGNOSING THE SOFT DIAGNOSING THE SOFT TISSUE INJURYTISSUE INJURY

SkinSkin Open fractures, degloving injuries and ischaemic necrosisOpen fractures, degloving injuries and ischaemic necrosis

MusclesMuscles Crush and compartment syndromesCrush and compartment syndromes

Blood vesselsBlood vessels Vasospasm and arterial lacerationVasospasm and arterial laceration

NervesNerves LigamentsLigaments

Joint instability and dislocationJoint instability and dislocation

SEVERE SOFT-TISSUE INJURY

TREATING THE SOFT TREATING THE SOFT TISSUE INJURYTISSUE INJURY

All severe soft tissue injuries………equire urgent All severe soft tissue injuries………equire urgent

treatmenttreatment Open fractures , Vascular injuries, Nerve injuries, Compartment Open fractures , Vascular injuries, Nerve injuries, Compartment

syndromes, Fracture/dislocationssyndromes, Fracture/dislocations

After the treatment of the soft tissue injury the fracture After the treatment of the soft tissue injury the fracture requires rigid fixationrequires rigid fixation

A severe soft-tissue injury will delay fracture healingA severe soft-tissue injury will delay fracture healing

DIAGNOSING THE BONE DIAGNOSING THE BONE INJURYINJURY

Clinical assessmentClinical assessment HistoryHistory Co-morbiditiesCo-morbidities Exposure/systematic examinationExposure/systematic examination

““First-aid” reductionFirst-aid” reduction

Splintage and analgesiaSplintage and analgesia

RadiographsRadiographs Two planes including joints above and below area of injuryTwo planes including joints above and below area of injury

TREATING THE FRACTURE TREATING THE FRACTURE II

Does the fracture require reduction?Does the fracture require reduction?Is it displaced?Is it displaced?Does it need to be reduced? (e.g. clavicle, ribs, Does it need to be reduced? (e.g. clavicle, ribs,

MT’s)MT’s)

How accurate a reduction do we need?How accurate a reduction do we need?alignment without angulation (closed reduction - alignment without angulation (closed reduction -

e.g. wrist)e.g. wrist)anatomic (open reduction - e.g. adult forearm )anatomic (open reduction - e.g. adult forearm )

TREATING THE FRACTURE TREATING THE FRACTURE IIII

How are we going to hold the reduction?How are we going to hold the reduction? Semi-rigid (Plaster)Semi-rigid (Plaster) Rigid (Internal fixation)Rigid (Internal fixation)

What treatment plan will we follow?What treatment plan will we follow? When can the patient load the injured limb?When can the patient load the injured limb? When can the patient be allowed to move the joints?When can the patient be allowed to move the joints? How long will we have to immobilise the fracture for?How long will we have to immobilise the fracture for?

DIFFERENT TYPES OF RIGID FRACTURE FIXATION

TREATING THE FRACTURE TREATING THE FRACTURE IIIIII

Operative Operative Non-optveNon-optve

RehabilitationRehabilitation RapidRapid SlowSlow

Risk of joint stiffnessRisk of joint stiffness LowLow PresentPresent

Risk of malunionRisk of malunion LowLow PresentPresent

Risk of non-unionRisk of non-union PresentPresent PresentPresent

Speed of healingSpeed of healing SlowSlow RapidRapid

Risk of infectionRisk of infection PresentPresent LowLow

CostCost ?? ??

INDICATIONS FOR INDICATIONS FOR OPERATIVE TREATMENTOPERATIVE TREATMENT

General trend toward operative treatment last 30 yrsGeneral trend toward operative treatment last 30 yrs Improved implants and antibiotic prophylaxis, Use of closed and Improved implants and antibiotic prophylaxis, Use of closed and

minimally invasive methodsminimally invasive methods

Current absolute indications:-Current absolute indications:- PolytraumaPolytrauma Displaced intra-articular fracturesDisplaced intra-articular fractures Open #’sOpen #’s #’s with vascular inj or compartment syn, Pathological #’s with vascular inj or compartment syn, Pathological

#’s#’s Non-unionsNon-unions

Current relative indications:-Current relative indications:- Loss of position with closed method, Poor functional Loss of position with closed method, Poor functional

result with non-anatomical reduction, Displaced fractures with poor blood result with non-anatomical reduction, Displaced fractures with poor blood supply, Economic and medical indicationssupply, Economic and medical indications

WHEN IS THE FRACTURE WHEN IS THE FRACTURE HEALED?HEALED?

ClinicallyClinicallyUpper limbUpper limb Lower limbLower limb

AdultAdult 6-8 weeks6-8 weeks 12-16 weeks12-16 weeks

ChildChild 3-4 weeks3-4 weeks 6-8 weeks6-8 weeks

RadiologicallyRadiologically Bridging callus formationBridging callus formation RemodellingRemodelling

REHABILITATIONREHABILITATION

Restoring the patient as close to pre-injury Restoring the patient as close to pre-injury

functional level as possiblefunctional level as possible May not be possible with:-May not be possible with:-

Severe fractures or other injuriesSevere fractures or other injuries Frail, elderly patientsFrail, elderly patients

Approach needs to be:-Approach needs to be:- Pragmatic with realistic targetsPragmatic with realistic targets MultidisciplinaryMultidisciplinary

Physiotherapist, Occupational therapist, District nurse, GP, Physiotherapist, Occupational therapist, District nurse, GP, Social workerSocial worker

COMPLICATIONS OF COMPLICATIONS OF FRACTURESFRACTURES

EarlyEarly LateLate

GeneralGeneral Other injuries Other injuries Chest infectionChest infection

PEPE UTIUTI

ARDS ARDS Bed soresBed sores

BoneBone InfectionInfection Non-unionNon-union

MalunionMalunion

Soft-tissuesSoft-tissues Plaster soresPlaster sores Tendon ruptureTendon rupture

N/V injuryN/V injury Nerve compressionNerve compression

Compartment syn.Compartment syn. Volkmann contractureVolkmann contracture

Enough for today….!!!Enough for today….!!!